Is mandatory treatment 'compassionate' to people with addictions? Not everyone agrees

When it comes to addressing the drugs crisis in Alberta, the kind of policy the United Conservative Party or the New Democrats would implement has much to do with how the parties understand the concept of compassion for people addicted to drugs.

The debate is perhaps best exemplified in the UCP's proposal to allow mandatory drug treatment. 

It's described as a policy that would allow for a family member, doctor, psychologist or police officer to make a petition to a specially appointed judge to issue a treatment order for someone who is in "imminent danger" to themselves or others. 

It would be a "last resort," the party said in making the announcement on Monday. UCP Leader Danielle Smith characterized the policy as "actual compassion," as compared to "looking the other way" and leaving someone to fend for themselves on the street.

The NDP, on the other hand, has characterized such an idea as "doomed to failure," both from a clinical and legal standpoint, and has suggested the better route is to emphasize harm reduction services, treatment beds, abstinence and other options.

All involved know mandatory drug treatment policies have long been controversial, not only in this province but across North America. It would raise various ethical and moral questions that aren't easy to answer. 

And though most argue the status quo is not a feasible option, not everyone is in agreement about whether such a policy would be effective — or whether it would just introduce new challenges.

Could be 1st such law in the country

It's hardly settled science, but various jurisdictions in Canada have been floating mandatory drug treatment as an option recently. British Columbia Premier David Eby has said he's contemplating the idea, and it's been raised as an issue in the Toronto mayoral debate. In the United States, Gavin Newsom, California's Democratic governor, introduced controversial "care" courts last fall, which run along the same lines.

But should the UCP plan be adopted, it would be the first involuntary treatment law in the country that would specifically target addiction. The province already has some laws on the books for specific circumstances, and youth with addictions can be put in care should their parents or legal guardians petition the courts.

Such an idea raises certain ethical questions around the rights of the individual. There are concerns around retraumatizing people who are forced into treatment, which could run the risk of those individuals developing a distrust in the health-care system. Plus, many worry about those who reject treatment relapsing and dying due to their reduced tolerance to drugs.

Discrimination is also a concern, said Monty Ghosh, an addictions medicine physician, because forced treatment can be a form of criminalization, which can disproportionately affect some groups and populations.

"The big purpose of decriminalization is to remove the stigma, which often prevents people from accessing care and treatment," said Ghosh, who is an assistant professor at the University of Alberta and University of Calgary.

On the other hand, some have argued that "smart enforcement," including court-ordered sobriety, has its place. 

Keith Humphreys is a professor of psychiatry at Stanford University and was a member of the White House Commission on Drug-Free Communities under U.S. President George W. Bush and a senior drug policy advisor in President Barack Obama's White House. He also recently served as the chair of Alberta's Recovery Expert Advisory Panel.

Humphreys said any policy that is going to apply the force of the state to get people to enter treatment needs to have monitoring for that person's rights and their consent, and to ensure they are treated respectfully.

But he said society needs to be realistic that some people will never enter voluntary treatment without pressure because "they will not be alive."

"I volunteer in a neighbourhood in San Francisco called Tenderloin, a big, open-air drug market and a lot of drug problems. I carry naloxone, the overdose rescue drug, with me," Humphreys said. "To somebody who's passed out and dying from an opioid overdose, I will administer naloxone without their consent. They can't consent. They're unconscious, and they're dying.

"And I think even a libertarian would say, 'Well, you know, that's OK.'"

So goes the debate with mandated treatment, in Humphreys' view, drawing a line in the sand concerning just how far we extend that principle.

The idea that people wouldn't be alive to seek voluntary treatment, for Ghosh, suggests a need to expand harm reduction, so that they would eventually be able to reach that treatment.

For him, the debate centres around one's capacity. If someone is in imminent danger of dying right away, someone has to intervene. But once that individual is alert and oriented, consent needs to be obtained.

"One of the big principles in our human rights is honouring our autonomy as individuals. By forcing mandated treatment, that autonomy is taken away. And that's the risk," he said.

On outcomes and motivation

Evidence around the effectiveness of mandated treatment can be interpreted in different ways, but Ghosh and Humphreys said studies have shown that people who are mandated to addiction treatment have outcomes about the same as people who go in voluntarily.

Here's where the ethical concerns again come into play.

"Some people say that if there's no benefit to mandated treatment compared to voluntary treatment, we should probably still do the mandated treatment, because it's better than doing nothing," Ghosh said.

"Whereas the voluntary treatment group says that you can definitely impinge on rights by forcing people to treatment. And that's where I think there's a bit more complexity that we need to look into."

Humphreys said even people in the "voluntary" group typically have something pushing them toward treatment, whether that be a family member, loved one, employer or neighbour.

"Those who spontaneously wake up and say, 'I really need to make a change in my life, and I'm going to seek care,' that's a pretty small proportion of people with addiction problems. Most people, there's some informal or formal pressure," he said.

That question surrounding what motivates an individual to seek change is a key element in this debate. Ghosh agreed that external incentives like family members can help drive that change.

"But what motivates you? Are you going to be more motivated because of external circumstances? Or would you be more motivated if someone forces you into this?" Ghosh said. 

"We know that motivation can be incentivized.… So we need to figure out other ways to motivate individuals to seek treatment without forcing them into it, because that might decrease motivation."

A deeply personal debate

Any conversation around this subject is certain to be among the most sensitive a government can have, especially since the drug crisis across the country has permanently altered the lives of so many.

Petra Schulz, who lives in Edmonton, is a co-founder of Moms Stop the Harm, a network of Canadian mothers and families whose loved ones have died due to fatal drug overdoses. Her son died of a drug poisoning in 2014.

For the last few weeks, she said, she's been talking with someone who is using drugs, who would be resistant to treatment and would likely face negative outcomes if forced into it. 

"When they use drugs, they know what they want. And they know when they're ready to make a change," Schulz said. "For me, this act is really a way of getting people out of sight that are unpopular or that are disturbing to the average public."

All of this, again, involves one's interpretation of what defines "compassion" when it comes to those people addicted to drugs. For Humphreys, the Stanford University professor, it involves specific cases.

"If someone gets to the point where they're doing great harm to other peoples' well-being and other peoples' freedom, or they're in a situation where they're in acute danger to themselves if they are not helped, then there is a compassionate case to say there needs to be some intervention," he said.

Given the demands such a policy would have on Alberta's health-care system, Schulz also had questions around whether it even had capacity for an influx of individuals receiving treatment.

Lisa Blahey, a spokesperson with Alberta Mental Health and Addiction, said there are more than 29,000 publicly funded addiction treatment spaces across the province, including detox, treatment and recovery spaces.

Ghosh said investments the provincial government has made into expanding services were positive developments, but more needed to be done.

"I think they're moving towards building that capacity. But again, speaks to this whole idea of mandatory treatment being a bit more premature, when we still need to build more capacity to get people into voluntary treatment," he said.

Alberta's provincial election is on May 29.